Medicare Pressure Reducing Support Group II – LCD Coverage
For these items to be covered by Medicare, a written order prior to delivery (WOPD) is required. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and to THE NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about WOPD prescription requirements.
A group 2 support surface is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3):
- The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (ICD-9 707.02-707.05) which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following (MUST BE DOCUMENTED BY WOUND CARE WITH DEPTH)
- Use of an appropriate group 1 support surface, and
- Regular assessment by a nurse, physician, or other licensed healthcare practitioner, and
- Appropriate turning and positioning, and
- Appropriate wound care, and
- Appropriate management of moisture/incontinence, and
- Nutritional assessment and intervention consistent with the overall plan of care
- The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (ICD-9 707.02-707.05),
- The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (ICD-9 707.02 -707.05), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days
If the beneficiary is on a group 2 surface, there should be a care plan established by the physician or home care nurse which includes the above elements. The support surface provided for the beneficiary should be one in which the beneficiary does not “bottom out” (see Appendices section).
When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery.
When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not reasonable and necessary.
A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Pressure Reducing Support Surfaces – Group 2 Policy Article will be denied as not reasonable and necessary. (See Coding Guidelines and Documentation sections concerning billing of E1399.)
Continued use of a group 2 support surface is covered until the ulcer is healed, or if healing does not continue, there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the group 2 support surface is reasonable and necessary for wound management.